Sleep and Sleep Disorders in Children and Adolescents: Information for Parents and Educators

Physicians
and psychologists estimate that as many as 30% of children may have a sleep
disorder at some point during childhood. Sleep disorders have implications both
for social-emotional adjustment and for school performance. For this reason it
is important for both parents and educators to understand how sleep works and how
disruptions in normal sleep patterns can affect children and teenagers. This
handout will provide an introduction to normal sleep patterns, definitions and
descriptions of the kinds of sleep disturbances that may affect children and
adolescents, and a brief description of recommended treatments.

Normal Sleep Patterns

Types of
Sleep Patterns

Sleep is
broadly classified into two types: REM (rapid-eye-movement) sleep and non-REM
sleep (NREM). By studying brain wave patterns we know that NREM sleep consists
of several stages, ranging from drowsiness through deep sleep. In the early
stages (Stages I and II) you awake easily and may not even realize that you
have been sleeping. In the deeper stages (Stages III and IV) it is very
difficult to wake up, and if you are aroused you are likely to find yourself
disoriented and confused. In NREM sleep your muscles are more relaxed than when
you are awake but you are able to move (although you do not because the brain
is not sending signals to the muscles to move).

REM sleep is
more active. Breathing and heart rate become irregular, your eyes move rapidly
back and forth under your eyelids, and control of your body temperature is
impaired so that you do not sweat when you are hot or shiver when you are cold.
Below the neck, however, you are inactive because the nerve impulses that
travel down the spinal cord to body muscles are blocked. Your body is
essentially paralyzed. It is during this sleep stage that you dream.

Developmental Characteristics

Infants and
children. Both these
sleep states develop before birth. Infants cycle through many sleep periods
throughout the day. As they develop, they sleep longer at night and have fewer
sleep periods during the day. Newborns sleep almost all the time. By 6 months
they sleep about 13 hours a day with the longest sustained period being about 7
hours. By 24 months children sleep for 12 hours, including naps, and by 4 years
children sleep 10–12 hours with one daytime nap at most.

Throughout
childhood children typically get about 10 hours of sleep a night. This drops
significantly at adolescence, but less for biological reasons than for
socio-cultural reasons. Sleep researchers studying the optimal sleep periods of
teenagers have found that when the sleep-wake cycle is studied in the laboratory
under controlled conditions (e.g., removing clocks and lighting cues),
teenagers typically sleep 9 hours a night. In the real world—especially during
the school year—very few teenagers get this much sleep and thus are constantly
coping with sleep debt to a greater or lesser degree.

Whereas
infants enter into REM sleep immediately, young children move quickly from
drowsiness and the lighter sleep stages to Stage IV, then experience cycles of
light to deep sleep, arousal, etc., eventually cycling between REM and Stage II
sleep, much like the sleep patterns of adults.

Adolescents. Adolescent sleep patterns deserve
particular attention because of the potential impact on school performance. It
has only been in the last 20 years or so that sleep researchers have recognized
that there are distinctive changes in sleep patterns in adolescence. There are
changes in the biological clock (also called circadian rhythms) of teenagers.
With the onset of puberty, teenagers begin to experience a sleep phase delay
such that they develop a natural tendency both to fall asleep later in the
evening and to wake up later in the morning. Even youngsters who have
experienced sleep deprivation (and therefore accumulated some sleep debt) tend
to feel more alert in the evening, thus making it more difficult to go to bed
at what parents might consider a reasonable hour.

The onset of
sleep is triggered by the release of melatonin, a natural body hormone. Toward
dawn, melatonin shuts off as another hormone, cortisol, increases, signaling
the youngster to wake up. Research shows that the pattern of melatonin
secretion makes it hard for teenagers to fall asleep early in the evening and
to wake up early in the morning. Schools with early start times (any time
before 8:30 a.m.) place students at a disadvantage in terms of arousal and
alertness—not only for early morning classes but throughout the day because the
adolescent’s biological rhythms are out of sync with typical school routines.

Recognizing and Treating Sleep Disorders

Some sleep disturbances
are mild, fairly common, and fairly easy to treat. Others may be more stubborn,
or they may be signs of potential physical problems that could have long-term
consequences if left untreated.

Diagnosis

Sleep
disorders are generally diagnosed either by a pediatrician or a sleep
specialist. If parents are concerned about possible sleep problems, they may
want to begin by discussing their concerns with their child’s physician. Not
all pediatricians recognize the variety of sleep problems children and
teenagers experience, and if parents are not satisfied after meeting with their
child’s physician, they may want to request a referral to a sleep specialist or
to a sleep clinic.

At school
parents might find some assistance from the school psychologist or social
worker, who may use a diagnostic interview as part of an evaluation. This
interview should include questions about the child’s normal sleep patterns,
including bedtime routines, typical bedtime and wake time on school days and
weekends, whether the child has trouble falling asleep or staying asleep, and
the frequency of nightmares. When parents or teachers have concerns about both
attention and behavior problems, sleep problems may be an issue. This is
because side effects associated with sleep disturbance or deprivation include
inattention, irritability, hyperactivity, and impulse control problems.

Treating
Sleep Disorders

Different
types of sleep disorders call for different treatments.

Night
terrors. Night
terrors are sudden, partial arousal associated with emotional outbursts, fear,
and motor activity. Occurring most often among children ages 4–8 during NREM
sleep, the child has no memory of night terrors once fully awake. If your child
experiences night terrors, make sure he or she is comfortable but do not wake
the child. In extreme cases, night terrors may require medical intervention.

Sleep
walking. Sleep
walking is most common among 8–12 year-olds. Typically, the child sits up in
bed with eyes open but unseeing or may walk through the house. Their speech is
mumbled and unintelligible. Usually children will outgrow sleepwalking by
adolescence. In the meantime, take safety precautions (e.g., using a first
floor bedroom), but keep efforts to intervene to a minimum. Awakening the child
on a regular schedule can reduce or eliminate episodes.

Nighttime
bedwetting. This type
of bedwetting is a common sleep problem in children ages 6–12, occurring only
during NREM sleep. Primary enuresis (the child has never been persistently dry
at night) is associated with a family history of the problem, developmental
lag, or lower bladder capacity, and is unlikely to signal a serious problem.
Secondary enuresis (a recurrence of bedwetting after a year or more of bladder
control) is more likely to be associated with emotional distress. Interventions
include use of reinforcement and responsibility training (such as keeping a dry
night chart), bladder control training, conditioning (e.g., bedwetting alarms),
and sometimes medication. In the case of secondary enuresis it might be most
helpful to determine any source of emotional stress and address it directly.
(For example, if a child starts wetting the bed at night following parents’
separation or divorce, providing counseling to address loss issues might help
alleviate bedwetting.)

Sleep-onset
anxiety.
Sleep-onset anxiety refers to difficulty falling asleep because of excessive
fears or worries. The problem may be caused by stressful events or trauma or
because of ruminating on more commonplace issues of the day. This type of sleep
problem is most common among older elementary school children. Intervention
strategies include reassurance, calming bedtime routines, and, in some cases,
cognitive-behavioral therapy, which is designed to help children develop
effective coping strategies to address their worries.

Obstructive
sleep apnea. Although
more common in adults, 1–3% of children experience difficulty breathing because
of obstructed air passages. Symptoms include snoring, difficulty breathing
during sleep, mouth breathing during sleep, or excessive daytime sleepiness. In
children this type of sleep disturbance is usually not serious, but most
children benefit from removal of the tonsils and adenoids. When this is not
effective, the condition can be treated (by a physician) with a procedure known
as nasal continuous positive airway pressure (CPAP).

Nacrolepsy. Nacrolepsy is a rare but
potentially dangerous, neurologically based genetic condition that may include
sleep attacks (irresistible urges to sleep), sleep-onset paralysis, or
sleep-onset hallucinations. It affects 1 of every 2,000 adults and may first
appear in adolescence. If this disorder is suspected, refer to the child to a
sleep specialist. Treatment may include ensuring a full 12 hours of sleep per
night or more, scheduled naps, or medication.

Delayed
sleep-phase syndrome. This is a
disorder of sleep (circadian) rhythm that results in an inability to fall
asleep at a normal hour (e.g., sleep onset may be delayed until 2–4 a.m.) and
results in difficulty waking up in the morning. Symptoms among children include
excessive daytime sleepiness, sleeping until early afternoon on weekends,
truancy and tardiness, and poor school performance. Treatment might include
light therapy (exposure to very bright light in the morning), chronotherapy
(gradually advancing the child’s sleep schedule 1 hour per night until a normal
routine is achieved), maintaining a consistent sleep schedule, or a short
course of sedative medication to help achieve a new schedule. It may be
necessary and beneficial to (temporarily) adjust the child’s school day to
allow for a later start.

Help for Children and Families

A sleep
disorder not only results in a sleepy, cranky, and often poor-performing
student at school, but also an irritable, unhappy child or teenager at home. A
youngster with a disrupted sleep pattern more than likely is wreaking havoc on
the sleep and patience of other family members.

If you
suspect that your child or teen has a sleep problem that goes beyond a few
nightmares or restless nights, do not delay seeking help. Start with your
family physician. The earlier a sleep problem is identified and treated, the
more quickly a normal sleep routine can be restored—for everyone.